U.S. Risk Underwriters, Inc. Boston (617.227.1310) Dallas (800.232.5830) Houston (800.833.8803) MISCELLANEOUS HEALTH CARE HOME HEALTH PROFESSIONAL AND GENERAL LIABILITY APPLICATION CLAIMS MADE AND REPORTED BASIS. PLEASE TYPE OR PRINT IN INK Effective date desired: 1. Complete name of facility (applicant) (if other than parent firm, supply full details of ownership entity) (use an additional sheet of paper if necessary): Address: City: State: Zip: County: Contact name: Title: Email address: Phone: Web site Address: Fax: List all other locations (use an additional sheet of paper if necessary): 2. In what state is the facility domiciled? 3. Applicant is: a. Individual Partnership Corporation Professional Association Other: 4. Date established: / b. Not for profit For profit Both 5. List all states where you are licensed to practice: 6. Is the firm engaged in, owned by or associated with or controlled by any other business? Yes No If yes, give details (use an additional sheet of paper if necessary): 7. Please list the individual shareholders or partners of the facility: 8. Are any services provided outside of the United States? Yes No If yes, please explain, including what countries, what type of services are provided and what percentage of your revenues are derived from these services: 9. Do you provide any internet services? Yes No If yes, please attach an explanation, including confirmation of licensing in all states in which services are provided. 10. Does the applicant anticipate any facility expansions within the next year? Yes No If yes, please describe: USRISKHHC 03.14 Page 1 of 7
11. Does the applicant own (wholly or in part), operate or administer any other business or other institution where medical services are customarily rendered? Yes No If yes, give details: 12. Does the applicant advertise its professional services in any manner (other than a simple listing in a telephone directory? Yes No If yes, please attach a copy of ALL of the advertisements. 13. Does the applicant participate in any activity, e.g. newspaper columns, broadcasts, etc., whereby professional advise is offered to the public? Yes No 14. Hold Harmless (Indemnification) Agreements: (a) In favor of the applicant: if the applicant has obtained any written indemnification agreements holding the applicant harmless, please describe and indicate if certificates of insurance are obtained: (b) In favor of others: has the applicant agreed to indemnity (hold harmless) others under written contract? Yes No If yes, please submit a copy of the agreement. 15. Is the Applicant a Covered Entity under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) Privacy Rule? Yes No If yes, (i) Has the Applicant implemented procedures to comply with the HIPPA Privacy Rule? Yes No (II) Provide the name and title of the Applicant s Privacy Officer. 16. Do you have any contracts with any of the following? a. Hospitals? Yes No If yes, what is the percentage of total revenues from this contract? % b. Nursing Homes? Yes No If yes, what is the percentage of total revenues from this contract? % c. Other Entities? Yes No If yes, what is the percentage of total revenues from this contract? % Describe: 17. State the number of patient encounters as follows (patient encounters refer to number of visits not number of patients): Number for last 12 months Estimated Number for Next 12 Months 18. Location and percentage where services are provided (total must equal 100%): LOCATION PERCENTAGE Private Home % Assisted Living % Hospital % Nursing Home % Other (specify): % 19. Type of services provided along with the percentage (total must equal 100%): SERVICES PERCENTAGE Skilled Nursing Care % Personal Care Chore or Companion % Physical/Occupational/Speech Therapy % Infusion Therapy % Pediatric Care (percentage of persons under age 18) Must be complete % USRISKHHC 03.2014 Page 2 of 7
20. State the number of patient encounters and/or patient tests carried out as follows (patient encounters refer to number of visits not number of patients): Type of Encounters Patient Encounters Patient Tests Number for Last 12 Months Estimated Number for Next 12 Months 21. State sources and amounts of actual and projected gross revenue: Amount this Source Fiscal Year Amount Next Fiscal Year a. Charitable Contributions b. Government Funding c. Fee for Service 22. Do any of your employees or independent contractors provide services as directed by you to members of their own family? Yes No 23. Do you provide imaging services? Yes No If yes, complete the supplemental application. 24. Describe the type of procedures performed at or by this facility: 25. Are all personnel performing these procedures certified and properly trained to perform these procedures? Yes No 26. Please schedule all of your employees and independent contractors: DISCIPLINE EMPLOYEES Independent CONTRACTORS # Full Time # Part Annual Hrs. Annual No. of Annual Hrs. Time Worked Payroll Contractors Worked Administrator Physician Psychiatrist Psychologist Doctorate Psychologist Bachelors/Masters Counselor Other Social and Case Workers Occupational Therapist Respiratory Therapist Physical Therapist Speech Therapist Therapist Aide Nurse RN Nurse LPN/LVN Nurse Practitioner Nurse Aide Home Health Aide Pharmacist Pharmacy Assistant General Clerical or Maintenance Medical Technician Homemaker/Provider/Caregiver USRISKHHC 03.2014 Page 3 of 7
27. a. Do Aides and/or Homemakers have CPR or First Aid Training? Yes No b. Are all the above individuals licensed in accordance with applicable state and federal regulations? Yes No If no, attach an explanation. c. Is continuing education or staff development required for your employees? Yes No d. Do you place health care staff with other businesses? Yes No If yes, what percentage of your revenues is derived from the placement of: Nurse Practitioners? % Other health care providers? % e. If you use subcontractors, do subcontractors carry their own coverage? Yes No If yes are limits of coverage equal to or greater than your limits? Yes No If no, attach an explanation. f. Does the applicant have any independent contractors? Yes No If yes, list the number and type of independent contractors who provide professional services on behalf of the applicant: g. Name of medical director, if any: (i) Is coverage provided for the medical director under any other insurance policy? Yes No (ii) If yes, please provide type of policy and name of carrier: HIRING PRACTICES 28. Do you require signed applications on all prospective employees? Yes No 29. Do you verify all professional qualifications, licenses and certifications? Yes No 30. Do you conduct a personal interview with prospective employees and non employees? Yes No 31. Do you require professional and personal references on each employee? Yes No 32. Do you conduct a criminal background check? Yes No 33. Do you provide training and orientation for new employees? Yes No 34. Do you follow up on any pending license suspensions or revocations or any pending disciplinary actions? Yes No 35. Do you ask if there have been any professional liability or work related claims made against the applicant in the past? Yes No 36. Do you have written job descriptions? Yes No 37. Do you require drug/alcohol screening? Yes No RISK MANAGEMENT/LOSS CONTROL 38. Is there a written, formalized Risk Management Program? Yes No 39. Is there a written, formalized Quality Assurance Program? Yes No 40. Do you have a standard system to handle a patient s complaints or suggestions? Yes No 41. Do you practice universal precautions? Yes No 42. Do you have a Quality Assurance Department? Yes No 43. In case of an emergency is management available 7 days a week, 24 hours a day? Yes No 44. Do you have policies and procedures in place regarding medications? Yes No 45. Are nursing charts maintained regularly? Yes No 46. Do you regularly check employees licenses and certifications? Yes No 47. Does your staff employment application include questions about whether the individual has ever been convicted of any crime, including sex related or child abuse related offenses? Yes No 48. Do you discuss at staff orientation elder and/or child abuse or sexual abuse? Yes No 49. Do you have a supervision plan in place that monitors staff in the daily relationships with clients? Yes No GENERAL LIABILITY 50. Complete the following for any owned or leased premises (use a separate sheet of paper if needed): LOCATION ADDRESS OCCUPANCY SQUARE FOOTAGE Owned Owned Owned Leased Leased Leased USRISKHHC 03.2014 Page 4 of 7
51. Are you required to name your landlord or any other business as an additional insured? Yes No (If yes, please list name and address of each and state interest. Use separate sheet if required.) NAME ADDRESS INTEREST 52. Do you supply or sell any medical supplies or equipment to patients or clients? Yes No 53. Do you rent or lease or supply any medical or therapeutic equipment to patients or clients? Yes No If the answer to Question 52 or 53 above is yes, please complete the following: Category I Expendable Items intended for one time use and then disposed Category II Category III Category IV Non Expendable Items including hospital beds, bathroom safety bars, portable toilets, lifts or hoists, ambulatory aids (excludes diagnostic treatment equipment devices) Diagnostic or Treatment Devices including oxygen and other medical gasses used in conjunction with respiratory therapy (excluding ventilators) Life Sustaining or Critical Monitoring Equipment or Devises including dialysis or heart/lung machines, all monitors Annual Rental Receipts: Annual Rental Receipts: $ $ 54. Do you install, service or demonstrate products or equipment? Yes No INSURANCE AND CLAIM INFORMATION 55. Do you currently carry the following: a. Professional Liability Insurance? Yes No List the Professional Liability Insurance carried by the firm for each of the past five years including periods of no coverage. Policy Period From: To: MM/DD/YY MM/DD/YY Insurance Company Limit of Liability Deductible Policy Form: Claims Made or Occurrence? Premium If claims made, what is the retroactive date/prior acts date on your current policy? b. Commercial General Liability Insurance?... Yes No If yes, list the Commercial General Liability Insurance currently carried by the firm: Policy Period Carrier Limit of Liability BI/PD Deductible Policy Form: Claims Made or Occurrence? Premium If claims made, what is the retroactive date/prior acts date on your current policy? 56. CLAIMS HISTORY: USRISKHHC 03.2014 Page 5 of 7
a. During the past five (5) years, have there been any professional or general liability claims or incidents made against you, any employee or former employee, the applicant or anyone proposed for this insurance? Yes No ATTACH CURRENTLY VALUED COMPANY LOSS RUNS FOR THE PRIOR FIVE (5) YEARS IF NO PRIOR COVERAGE, COMPLETE ATTACHED CLAIM SUPPLEMENT b. Are you, or anyone proposed for this insurance aware of any fact(s), incident(s), act(s), event(s), circumstance(s) or occurrence(s) that may result in a claim(s) being made against you? Yes No If yes, provide full details. c. Have there been any prior complaints or incidents reported arising out of alleged or actual physical or sexual abuse or molestation? Yes No If yes, fully describe the circumstances and follow up action taken: THE APPLICANT DECLARES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE INCEPTION DATE OF THE POLICY PERIOD, WILL IMMEDIATELY NOTIFY THE UNDERWRITERS OF SUCH CHANGE. SIGNING OF THIS APPLICATION DOES NOT BIND THE UNDERWRITERS TO OFFER, NOR THE APPLICANT TO ACCEPT INSURANCE; BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE INSURANCE AND MADE A PART OF THE POLICY SHOULD A POLICY BE ISSUED. APPLICABLE IN THE STATE OF NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONTAINING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. *Notice applicable in most states: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance, or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact, commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty. I/We hereby declare that the above statements and particulars are true and I/we agree that this application shall be the basis of the contract with the insurance company. / Applicant s Signature Title Date USRISKHHC 03.2014 Page 6 of 7
PLEASE INCLUDE THE FOLLOWING INFORMATION WITH YOUR SUBMISSION: 1. COPY OF 5 YEAR CURRENTLY VALUED HARD COPY COMPANY LOSS RUNS 2. COPY OF THE DECLARATION PAGE OF YOUR MOST RECENT PROFESSIONAL LIABILITY POLICY 3. IF A START UP FIRM, COPY OF THE PROFORMA BUSINESS PLAN 4. COPY OF ANY ADVERTISING BROCHURES OR ADVERTISEMENTS 5. COPY OF A SAMPLE CLIENT CONTRACT 6. RESUMES/CV S FOR ALL KEY PERSONNEL, PRINCIPALS, EXECUTIVES, MEDICAL DIRECTORS AND/OR ADMINISTRATORS Limits of Liability desired for Professional Liability: $100,000/$100,000 $250,000/$250,000 $500,000/$500,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/3,000,000 Other: $ /$ Deductible desired: $2,500 $5,000 $10,000 $25,000 $50,000 Other: MINIMUM AND MAXIMUM DEDUCTIBLES WILL BE SUBJECT TO UNDERWRITING APPROVAL. USRISKHHC 03.2014 Page 7 of 7